Yudu - sportEX medicine - 1999-2010

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posterior compartment of the thigh Presentation: This condition can present after an acute traumat- ic incident usually a contusion, causing a haematoma and build up of pressure within the involved compartment. Posterior com- partment syndrome is more likely to present in a chronic form resulting from overuse. There is muscle hypertrophy and inflam- mation of the muscle and surrounding fascia with activity, the resulting increase in fascial compartment pressure causes muscle ischaemia and pain. The pain usually follows prolonged activity and is not present once activity ceases Assessment: The patient complains of tight hamstrings but there is little reduction in straight leg raise. Resisted tests are negative, with the patient neither reporting pain or a decrease in strength Treatment/rehabilitation: Conservative treatment involves improving blood flow within the involved compartment through the use of stretching and strengthening exercise and massage. Surgical management in the form of a fasciotomy has also been advocated, especially in the case of traumatic acute onset com- partment syndrome.

3. Hamstring syndrome Definition: Pain in the posterior thigh and lower gluteal area occurring in sitting, stretching and sprinting but without a trau- matic mechanism of injury Cause: The problem is caused by tight fibrotic bands of tissue, gen- erally in the biceps femoris muscle. These bands compress and irri- tate the sciatic nerve (Fig.2) close to the ischial tuberosity, which causes pain to radiate down the posterior thigh Presentation: The pain is often felt on sitting and has been described as relentless and requires the patient to stand up. The patient fails to report a traumatic incident causing the pain Assessment: There is tenderness on palpation around the ischial tuberosity and occasionally pain on straight leg raise and hamstring stretching

Treatment/rehabilitation: Surgical intervention has been shown to be effective in these cases, with division of the fibrous bands.

4. Ischiogluteal bursitis Definition: Inflammation of the ischiogluteal bursa Cause: Repetitive irritation of the bursa, lying between the ischial tuberosity and gluteus maximus, ie. by the seat when rowing Presentation: Gradual increase in pain with activity which may not rapidly decrease with cessation of the activity. Walking, running and sitting could all stress the inflamed bursa Assessment: Pain will be present on palpation of the bursa, found between the ischial tuberosity and gluteus maximus, and is best palpated with the hip on the affected side flexed and abducted into a frog-leg position while prone. Straight leg raise may be limited and painful, resisted knee flexion will be pain-free and full strength Treatment/rehabilitation: Correction of the cause (the irritation) for instance changing seating position when rowing may alleviate the symptoms. Stretching of tight structures particularly the ham- strings and gluteus maximus is also effective.

5. Adverse neuromeningeal tension Definition: Abnormal physiological and mechanical responses of a nerve to the application range of movement tests Cause: Inflammation and scarring of any of the interfaces the sci- atic nerve passes through can interfere with normal mobility, pro- ducing greater tension within the nerve and an adverse reaction to lengthening Presentation: The patient will usually present with a history of injury to one or more of the interfaces the sciatic nerve passes through, for instance previous hamstring muscle injury or low back or sacro-iliac joint pain. The pain will be activity related, increas- ing as activity progresses (in the later stages of the condition there may be a constant background ache in the thigh). Activities which bring on the pain will be those which tension the sciatic nerve eg.

Gluteus medius Piriformis

Quadratus femoris

Trochanteric bursa of gluteus maximus

Adductor magnus Gracilis

Semitendinosus Semimembranosus Hamstrings

Biceps femoris long head

Route of the sciatic nerve down the thigh

Figure 1: Posterior view of the thigh showing the three muscles that comprise the hamstrings